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"R.E.A.C.H." Clinical Portal Making a Difference in Doctors' and Patients’ Lives

R.E.A.C.H. or "Rapid Electronic Access to Clinical Health Information"is an electronic health information portal that allows authorized users access to their patients’ clinical information through a secure web-browser, whether inside or outside of the hospital.

This means Lab and Diagnostic test results, images, transcriptions and progress reports written (at any one of the REACH partner Hospital's) can be viewed immediately by a Physician treating the patient. Currently the REACH portal includes The Credit Valley Hospital William Osler Health Centre, and Halton Health Care. Trillium Health Centre and Headwaters Health Care Centre will be joining the network soon and Hamilton Health Sciences and the Scarborough Hospital also use the same vendor solution. Sharing Patient's clinical information is important because patients move between facilities for across a region to access different types of diagnostic tests and/or procedures---that are not necessarily performed at all facilities. At the Credit Valley Hospital, one of the Physicians was asked what he thought of this new EHR initiative. Here’s what he said.

Dr. Tom McGowan’s Notes*: Wednesday October 15, 2008
Sitting in clinic today it struck me how quickly REACH has changed how I work. Today was a day when I saw new cancer patients with new problems. Of the four new patients I saw today, I needed to look into REACH to get information from other hospitals on two of them. It took seconds to look them up, and find the information I needed from the other hospitals. Before REACH, getting that information would have taken anywhere from 15 minutes to hours, and usually many phone calls.

Given that we’re the only Radiation program in the region, we always see patients who have had all, or large portions, of their care elsewhere. Most of the time the referring doctors make sure all the information is faxed over when the referral is made. Most of the time we can make the decisions we need to make with the information we have. But if there was a recent test, or clinic visit, then we should see that report before we make a final treatment recommendation.

There’s wasted time and effort when information comes in piecemeal. There are times when the results of the test aren’t available when the patient is first referred by their medical doctor (MD). Sometimes the referring MD will send it when it’s ready, and sometimes not. We can’t expect that to happen because it’s too much to ask a busy referring doctor to keep track of upcoming tests, and make sure they’re faxed to us, when ready.

Even if it is sent after the result is in, we’ve got to be sure the new information gets attached to the original. While this normally happens, I’ve had cases where I’ve had our staff call a referring hospital to get a test result faxed over. Sometimes they say they’ve already sent it but we don’t have it. So we get them to send it again, only to find it went to my office rather than my clinic.

When there appear to be duplicates of the same test, there’s more time wasted while I compare the results from the two documents. Only then can I be sure it’s not new information that will influence the patient’s care. It’s pretty obvious that this isn’t the most efficient way to manage anybody’s time. Now I have an advantage that I hadn’t really appreciated until I started to use the REACH portal. By looking at the records from other hospitals, we can sometimes see results of tests that are relevant, but that the patient didn’t realize could be useful, or had completely forgotten about. This type of thing doesn’t happen very often, but when it does, it matters.

So getting back to today; I had two patients that had information I needed from other hospitals. Thanks to REACH, I had it, easily after looking for a few seconds. I didn’t have to figure out what to ask for, where things might have been done, and deciding whether I really needed it in the first place. I was able to spend all my clinic time doing clinical work, seeing my patients, explaining things to them, and figuring out what they needed to do next. And that makes for a satisfying day.

*Dr. Tom McGowan is Physician Director, Radiation Oncology at The Carlo Fidani Peel Regional Cancer Centre located at The Credit Valley Hospital.



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Original article published in "A Credit to your Health" AUTUMN 2008 / VOLUME 10 ISSUE 4.

Rebooting Canadian Healthcare using eHealth Portals

by Dan Germain, VP, Chief Financial and Information Officer, The Credit Valley Hospital as published in Canadian Healthcare Technology Magazine | Vol.12, No. 8 | Nov/Dec 2007.

According to recent statistics from the Canadian Institute for Health Information, as many as 24,000 Canadians die each year from adverse events like surgical errors, patients receiving the wrong medication, and hospital-acquired infections. As the practice of medicine today is inherently dependent upon healthcare technology, the accountability and sustainability of our healthcare system depends on the ability of healthcare practitioners to find ways of gaining efficiencies and increasing effectiveness in every aspect of their daily activities.

All levels of government across Canada are experiencing pressures today to cut healthcare delivery costs, while increasing the level patient safety and care. With this demand for managed care, technology is quickly evolving to meet new and more complex requirements, with significant benefits to medicine and healthcare overall. As Charles Darwin so aptly identified: “It is not the strongest of the species that survive, nor the most intelligent, but the one most responsive to change.” In the past, the acquisition of technology was viewed as the answer in and of itself. Decisions about technology and usage were typically driven by the question of how to improve the effectiveness of what hospitals were already doing. However, today’s information systems should be viewed as a vehicle to transform current hospital processes into what they could and should be doing.

At the same time, there is a demonstrated understanding for the need to update technology systems in order to extend a national electronic health record (EHR) in Canada. Healthcare stakeholders agree that technology is critical to facilitating necessary information-sharing across disciplines and venues. Driven by Canadian Health Infoway, this movement embraces the need to evolve healthcare informatics toward a more open, standards-based, patient-centric model that brings together all imperatives: clinical, administrative, financial, managerial, and human resources.

With the information-sharing capabilities provided today by a rapidly expanding number of new technologies, Canadian healthcare organizations can leverage a crucial tool-set to support informed medical decisions at the point of care. To this end, healthcare providers and vendors both agree that a consistent, standardized way to share information between healthcare stakeholders can overcome the barriers to attaining an EHR.

One destination; Many paths
When any healthcare organization sets out to extend a ‘cradle-to-the-grave’ EHR – readily accessible via the Internet and linked to clinical protocols and guidelines — most people picture only one scenario. In this scenario, a user enters a patient query into one computer system, and that query goes to one source where all the patient information has been stored in a single “centralized” database, or vertical architecture. The system searches one database and returns the queried information to the user. The problem with this scenario, is that information is not best accessed in this manner as the required patient data resides somewhere in a disparate system.

However, this is not the only option. Instead of duplicating that patient data in a new centralized system, the healthcare organization could leave the existing data in place. Then, when the user enters a query about a patient, the system logically gathers the appropriate patient data from wherever it is stored. This approach is called a “federated” database model and employs a horizontal architecture. Anyone who uses the Internet takes the delivery of content from multiple systems for granted. Almost every Web page is automatically assembled from multiple sources, and employs a federated database model. One simply clicks a button and data is retrieved from disparate databases and servers.

By definition, a federated database is a collection of data stored on multiple autonomous computing systems connected by a network that is intuitively presented to users as one integrated database. Additionally, using a federated portal approach allows bandwidth, hardware, administration, and other infrastructure costs to be distributed over time, keeping pace with the development and deployment of the facility. This can significantly reduce networking and system-interfacing costs and opens up a number of added functional possibilities by extending data to the organization’s value chain delivering clear, tangible benefits for your short and long term needs. Compared to a centralized portal, today’s federated architecture can achieve equivalent or better results, at a fraction of the cost and time.

Follow the leaders
The Credit Valley Hospital (www.cvh.on.ca) is a vibrant community hospital providing leadership in the delivery of primary, secondary, and tertiary health care services to the people of Mississauga, Ontario and the surrounding LHIN-6 region. Serving more than 5,400 visitors daily, The Credit Valley Hospital (CVH) has provided patients with access to cutting-edge medical research, programs and treatment since 1985, recently opened a new Ambulatory Care Wing that offers both systemic (chemotherapy) as well as radiation therapy as a regional Cancer Centre. By 2011, CVH will have completed another expansion adding 145 new inpatient beds to the community. . As such, it’s not surprisingly to imagine that the 2,700 staff and nearly 400 physicians generate and store a significant amount of disparate data.

CVH recently implemented a MEDSEEK Web solution which facilitates various healthcare organizations to support vendor-neutral and enterprise-wide system interoperability. Due to the regional programs at CVH, it was critical that all departments were able to share data amongst its providers. The goal was to be able to provide the same information sharing capabilities among various healthcare facilities, nation-wide, as well as reduce redundancies like test duplications due to missing or unavailable information. After implementing the federated portal, CVH saw an immediate improvement in both patient flow and medical care throughout the hospital. Today, patient-data is immediately available from any computer with Internet access, whether the disparate data actually resides at the two sites (Etobicoke and Brampton) of William Osler Health Centre (www.williamoslerhc.on.ca) or at the three sites (Oakville, Milton, Georgetown) of Halton Healthcare (www.haltonhealthcare.com). The population served by these portals exceeds one million people residing in Mississauga, Brampton, Halton Hills, and Oakville.

Agfa Healthcare’s Clinical Dashboard™ (powered by MEDSEEK) is the only proven federated portal model in the country that addressed CVH’s unique pain points in an efficient and cost-effective manner. The portal met the organizations rigorous selection criteria by offering superior software and services, clinical integration experience, and the ability to expand to future enterprise eHealth solutions. The combination of ease of use, real-time data access and enhanced clinical functionality enhances patient care and clinical excellence, while extending a virtual EHR. In addition, the solution was implemented in only 90 days – at a fraction of the cost for a centralized portal solution – which was vital.

Jeff Lamb, Executive Vice President of Sales at MEDSEEK confirms those sentiments: Enhanced integration functionality throughout a medical enterprise yields immediate operational efficiencies including reduced paperwork, improved communications, better workflow management, and stronger relationships among clinicians, patients and the community. For CVH specifically, having connectivity to William Osler and Halton Healthcare facilities, the portal provides a virtual medical record of all patient data across multiple LHINs. This not only improves physician efficiencies but also contributes to enhanced patient safety and care.

The federated portal solution evolves Canada’s healthcare delivery toward a more open, standards-based, patient-centric model, at a fraction of the time and cost of the centralized portal approach. CVH expects this solution to significantly reduce surgical and medication errors while making lives easier for staff. Additionally, as CVH expands its portal solution to support PDAs, the portal will become even more valuable as patients will be able to ask their physician specific questions and have results available immediately. Ultimately, however, the biggest winner is the Canadian patient and taxpayer.

There’s no argument about the need for a better way to access information, reduce medical errors and increase the quality of patient care, and that technology plays a critical role in making this happen. However, using technology the way it’s always been used is not the best approach for the kind of radical change needed. Through examples like CVH, it’s clear that interconnectivity and information-sharing between hospitals, LHINs, and even across provinces is a reality, and can significantly benefit from a new, “federated” way of thinking.

Province of Ontario | Local Health Integration Network (LHIN) Map

For more information about a LHIN, please choose the appropriate link below.
1. Erie St. Clair
2. South West
3. Waterloo Wellington
4. Hamilton Niagara Haldimand Brant
5. Central West
6. Mississauga Halton
7. Toronto Central
8. Central
9. Central East
10. South East
11. Champlain
12. North Simcoe Muskoka
13. North East
14. North West


For additional information please visit Ontario's Local Health Integration Network (LHIN) web site.

The Healthcare Enterprise | Making a case for eHealth Investment

Many healthcare executives look at technology as a cost of doing business. However, investment in strategically chosen technology can enhance revenue while lowering operational costs. Labour, as an example, is the most expensive and valuable resource in a hospital. Therefore, any measurable improvement in the use and efficiency of labour can improve a hospital’s bottom line considerably.

Whether business office staff processing claims information, nurses performing patient assessments, or physicians diagnosing and treating patients, with the current disarray of disparate information databases (and wireless and remote technologies;) users are constantly striving to gather the information required in order to perform and optimize their job function. Strategic implementation of new Technology can significantly improve efficiency in:
• Clinical Operations (ex: Nursing, Physicians and ER)
• Financial Operations (ex: Contract Management, Administration and Registration and Accounts Payables and Material Management)
• IT Operations (ex: Training, Help desk, Network, etc.)

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CLINICAL OPERATIONS
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1. Nursing:
This is the primary area for patient care improvement and enhanced patient revenue. All aspects of technology must perform smoothly – and be transparent to the end user – or nursing will not use it for patient care. When this area is not supported by IT effectively, nurses and other clinicians will revert to paper as the only reliable way to record information regarding patient interventions and notes on the patient’s status. When this happens it significantly lengthens the process, potentially up to two hours per patient per shift. Furthermore it results in duplicate processes and redundant data capture – so much so the caregiver spends too much time managing the clerical tasks, and the patient care process is inhibited. Accurate and timely charging for patient procedures, tests and supplies do not always occur resulting in lost revenue for the hospital. The key technology elements that must all be operating effectively are:
• Robust Clinical Application System including Case Management and Scheduling
• System reliability (99.9% availability)
• System performance (instant response time)
• Easy to use and accessible system devices (e.g., wireless, PDA’s, tablets, printers, etc.)

2. Physicians:
Physicians’ have two main concerns
• time to see patients and
• the timely availability of accurate patient information.

Therefore, creating a way for physicians – no matter where they may be – to continuously receive updated information on their patients addresses both of their primary concerns. Providing this technology is a key contributor to recruiting and retaining satisfied physicians, as well as providing high-quality patient care. The key technology elements that must all be operating effectively are:
• Physician-oriented presentation of patient results information
• Easy-to-Use computerized physician order entry system
• Online access to patient’s diagnostic x-ray and ultrasound information (PACS)
• System reliability
• System performance
• Support for multiple input and output devices (e.g., wireless, PDA’s, tablets, printers, etc.) from in-hospital as well as remote locations
• Integration to their office practice management and EMR systems

3. EMR:
The ultimate goal of most healthcare organizations is a paperless electronic medical record to improve the efficiency and effectiveness of the enterprise workflow process and enhance the revenue generation process. Healthcare management understands, at a conceptual level, that having an automated digital hospital would improve the entire patient care workflow process, and thus, patient satisfaction and staff productivity. The successful automation of previously paper-based processes requires a robust IT infrastructure, and careful planning among all the affected stakeholders.

4. PACS:
A PACS system not only has proven to produce positive bottom-line results, but also is often considered a necessary precursor to the EMR. A wise investment that often pays for itself within 3-5 years, it allows the “reading” of images from all modalities from a workstation that is either in the hospital, or in a remote office. The biggest benefit however is the ability to transmit and view the image to wherever it is needed, and removes all of the barriers to access that exist with traditional film. To achieve all the available benefits, the network bandwidth must be in place to support very large image files, and again, careful planning among all the affected stakeholders is critical to a successful implementation.

5. ER:
Increasingly hospitals are realizing that their ER is a major entry point for patients and should not be overlooked as a revenue source. Providing comprehensive computerized systems that are optimized for the ER’s workflow are mandatory if the hospital desires to realize the potential benefits available. The key technology elements that must all be operating effectively are:
• Emergency Room Patient Tracking System
• System reliability
• System performance
• Easy to access and use input and output devices (e.g., wireless, PDA’s, tablets, printers, etc.)
• Seamless Integration to a hospital’s Master Patient Index to retrieve patient information and provide billing data
• Integration with the EMR to maintain a comprehensive clinical record.

6. Laboratory:
Laboratory orders are processed promptly because of the need of the patient. However, in a paper-based environment, charges can be overlooked because of the multiple steps required to process a patient chart and the extra work involved in capturing charges. A comprehensive Laboratory Information System (LIS) that is fully integrated with the HIS will alleviate this problem, as well as improve the overall efficiency and effectiveness of the Laboratory staff. The key technology elements that must all be operating effectively are:
• Robust Laboratory Information System including integration with all laboratory instruments
• Integration with hospital’s EMR and/or order entry system
• Integration with any external reference laboratory used to enable a complete view of patient’s lab results
• System reliability
• System performance

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FINANCIAL OPERATIONS:
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The key to strategic gains in the Financial/Administrative area is to invest in the newest technology that enables business processes to function more efficiently, and ensures the most accurate billing practices for the organization. Even small procedural changes can create more effective billing and substantially improve the bottom line. Likewise, the implementation of comprehensive scheduling systems can improve turnaround times and help ensure the optimal use of expensive fixed assets throughout the hospital. Other areas suitable for increased investment are described below.

1. Contract Management:
Many hospital billing operations submit claims based upon the personal knowledge of staff billers. Billers often overlook minute and incremental charge optimization opportunities simply because of the volume of bills and claims that must be generated and submitted. The computerization of code optimization and the underpayment analysis of payer reimbursement will have an ongoing and profound impact on a hospital’s bottom line. Whereas these billers are very knowledgeable, their true value is in the management and adjudication of claims denials. The loss of revenue per claim may be small, yet the total volume of claims equates to a substantial loss. Computerization of the claims submission and denial process quickly pays for itself and can immediately increase the hospital’s cash. The key technology elements that must all be operating seamlessly:
• Contract Management Application System
• System reliability (minimal downtime)
• System performance (immediate response time)
• Adequate storage (retrieve discharged patient’s complete information)
• Electronic interface to primary payors
• Integration with hospital’s patient accounting system

Hospitals will vary on the impact of automating these areas of operation. The cumulative effect can be quite surprising. As PriceWaterhouseCoopers and HIMSS analytics reported in their study of cardiac care in 36 hospitals in March 2005, there was an “85% reduction in medical errors and a 65% reduction in inappropriate denials from payors…” in the hospitals studied.

2. Admissions and registration:
This area requires system speed and a reduction in the complexity of screen layouts. There is typically a lot of turnover in this area. Yet Admissions is the first location for revenue enhancement and the primary source of errors and inaccurate data for billers to deal with claims denials. The key technology elements that must all be operating effectively are:
• Comprehensive admission-discharge-transfer system
• Integration with payors to confirm patient coverage
• Integration with patient scheduling system
• System reliability (no downtime)
• System performance (immediate response time)
• Easy to access and use input and output devices

3. Accounts Payable/Materials Management:
The goal of automating the replenishment of the hospital supplies (using just-in-time processes), while taking maximum advantage of the hospital’s contracts, in an effective and efficient process, has a significant impact on the hospital’s profitability. Accurate, ongoing, and continuous inventory, minimal loss of stock, and maximum chargeability are the key components. Taking advantage of discounts by being able to pay vendor’s invoices within the discount can benefit the hospital’s bottom line. The key technology elements that must all be operating
effectively are:
• Comprehensive Accounts Payable System
• Comprehensive Materials Management System
• Integration between Accounts Payable and Materials Management
• System performance (immediate response time)
• Easy to access and use
• Adequate storage

4. Barcoding:
It has been shown that barcoding data at the bedside, from the pharmacy, and through materials management reduces medical errors tremendously, as well as, improves the automation of input of data into the patient chart. It holds the ability to speed and integrate the purchasing, distribution, administration, charting, and billing for pharmaceutical and other supplies. An effective barcoding strategy not only provides more accurate and timely information, but also saves time and improves the work lives of clinicians, managers, and staffers by making things run more smoothly and simply. To realize the full benefits of a barcoding implementation, attention must be paid to the workflow changes necessary to get maximum returns. When combined with supply chain automation, the entire process of acquiring the correct supplies, packaged and correctly prepared for patient delivery, are made available to the care-giver when needed – and the documentation for billing, inventory reordering, and the patient chart, is captured as a by-product of the patient care process.

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IT OPERATIONS:
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The common thread in improving IT Operations in healthcare is to achieve maximum leverage of the staff resources to implement and support an ever-increasing array of emerging hardware and applications. Through continual centralization of the environment, more ROI is squeezed out of fixed assets and the staff becomes more efficient by giving them the tools to do their job more effectively. Whether it’s server administration, network management, application support, or user provisioning, the innovative investment in the IT infrastructure can improve service levels and ensure optimum utilization of expensive staff resources. Practical examples include:

1. Training:
As the general workflow process is automated, the need for personnel to understand how to use the tools at hand becomes paramount. Training is needed in two distinct areas; the IT staff and the users:
• The IT staff must be trained to understand how to use the servers, switches, software and network to maximize the users’ capabilities. Each IT staff member has a “multiplier effect” upon the user community’s effectiveness. Most should therefore be certified in their area of expertise.
• The automation process is for the benefit of the user and the organization. Therefore, the user must be trained in the optimal usage of the system and the tasks they perform. This means that an ongoing training program should be implemented to ensure employees are accomplished on the system(s) they use and fully understand the implication of their actions when using automated systems to perform their jobs.

2. Help Desk/ Service Level Management:
IT departments may have a phone number for users to call in case of need, however most facilities do not have an automated structured process to monitor
technology, diagnose problems, administer support, and measure performance by automated reporting. It is imperative to be able to understand the source of help desk calls in order to properly plan for the improvements needed to improve customer service.

3. Network:
The network is the nervous system of an organization’s information flow. There are a number of components of a network that must be able to transport data at a guaranteed minimum volume.

4. Switches, bridges, and routers:
The switches, bridges and routers are the devices that route data from one part of the network to another. Considering that a fully automated healthcare workflow process will have a minimum of 25 major applications that will route data for 30 departments, the switches need to be configured to handle the volume of traffic anticipated.

5. Backplane:
A backplane acts as a “traffic cop” for the data that comes from all of the different switches within the network. Therefore, it must handle the accumulated burstable volume of the network. For a fully integrated and automated workflow process, a backplane may need to burst to 4 Gigabytes/sec. of volume.

6. Network Management Software:
Many of the major network vendors have the ability to continuously “ping” the network through a technology called SNMP. This allows IT to proactively monitor the “health” status of switches, PCs and servers. The same software now also keeps an inventory of hardware and software, as well as version control, so that the network can now distribute patches, updates, and fixes to the users quickly. Finally, most of these network vendors now have integrated help desk and service level management automation into their support process. Therefore, IT can now receive a request for assistance, log it, prioritize it, and escalate it automatically. They can then diagnose and fix (either remotely or by the system dispatching a person) user’s hardware and software. Finally, the IT tools can then print out a report that shows the amount of time systems were up for the month, how many service calls were responded to by prioritized need, who was serviced and when, as well as the outcome of that service call.

7. Wireless and Remote Capabilities:
Wireless PDAs, tablet PCs, smartphones and laptops are transforming the way information is gathered and processed. Systems can now be structured so that physicians may plug their device into the hospital system and be uploaded with what happened to their patients overnight. Additionally, caregivers and hospital staff can now work from home.

8. VoIP:
Currently the dual networks and dual support staffs to run a network and a PBX system are costly. Time and again, the return on investment (ROI) to move the phone system onto the network, department by department over a period of time, has shown to be a good investment. There is no charge for moves, adds and changes (MACs) now, the administration of two systems can be handled internally by one group, and future cabling costs are minimized.

9. Cabling:
Cabling is an infrastructure issue and often its importance is overlooked. But, it is foundation of the information highway for a hospital. In addition, as hospitals are adding increasing computerization, cabling installed two years ago may soon be outdated. Cabling should be an integral part of a hospital’s computer plan.

10. Standardization:
Standardization means that the technical components of servers, switches, and PCs should have the same memory, cache, and storage. The reason for this is that servicing a few standards reduces the complexity of support, which has shown time and again to be the best way to reduce the cost of operations.

11. Servers:
Most servers are currently purchased as individual standalone machines. This creates two problems: first, it means that each server is a single point of failure for its own data and there is no failover capability from one server to another; and second, the storage usage of each machine is usually less than 50% of capability. Therefore, the architecture of servers should be configured into a storage array network (SAN) of blade servers configured to backup each other.

Conclusion:
The implementation and continued automation of the healthcare workflow process is analogous to building a house. All departments run their own operation, but are interconnected and dependent upon each other to provide a complete workflow environment. The foundation of said “digital house” however, is the technological infrastructure. Any weak points in the infrastructure will create bottlenecks in the workflow process. The demand for quick and accurate patient information in hospitals is continuously on the increase. Hospitals have to improve their technological infrastructure in order to meet the needs of caregivers and to enhance their revenue. Healthcare workflow process improvement will take time to accomplish in a coordinated, synergistic manner that will improve patient care and hospital revenue.